OT and Self Regulation

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Saturday, September 10, 2016

The latest issue (October, 2016) of the Autism journal contains an interesting study of how parenting styles affect self-regulation skills in children with autism. The article compares a child's temperament and ability to self-regulate with the parents' style of discipline and of interacting with their child.

In the study, 40 children with autism were matched to 40 children without autism. The initial assessment of temperament and self-regulation in the children with autism compared to their peers. Not surprisingly:

Compared to their typically developing peers, children with autism spectrum disorder showed more noncompliance and less self-regulated compliance to parental demands and prohibitions and greater temperamental difficulties across several domains.

No differences in parental disciplinary styles were found in the parents of children who were better regulated as opposed to those who were not. But there was a difference in parent-child interaction styles. Parents of children who were better self-regulated were found to offer more support to their children and to request better attention from them.

The authors concluded:

Findings highlight the importance of parental supportive presence in structuring the development of socialization in children with autism spectrum disorder.

Tuesday, August 16, 2016

Today was a dentist day. Now, in spite of being over-sensitive to just about everything, I am good with going to the dentist. As a child, I had a great dentist who told me to focus on something else while he worked on my teeth. I did so and got through the procedure without too much discomfort. It was a good lesson.

But I didn't generalize on it until much later. I was in the midst of a home remodeling project and hammered my thumb instead of the nail :{ I was dramatically in pain. A friend told me I was a wuss, and that I should focus my attention on something else until the pain died down. I did it, and miracle of miracles, it worked. How did he know that and I didn't. He had played sports. I had not. Sensory kids don't.do.sports because it's noisy and you get bumped a lot. And that's the point of this post sensory kids naturally react differently to pain, bumps and sounds and they avoid activities like sports where kids get so many life lessons, including "think about something else".

If Zoey is playing in the sprinkler and gets water in her face, she can focus on it with discomfort, or she can shift her attention outward to something else, like the sprinkler itself, her chest or her hands. If Martin is standing next to an alarm that sounds for several seconds, he can bring his attention back into his body (and his hands over his ears) and in that way stay grounded.

This particular lesson is a game changer, and here's why. Our brain operates with great efficiency, always trying to guess what to be ready for. If I focus on sensory discomforts, the brain says, "That's what she wants to pay attention to", and so it prioritizes the brain's focus to discomforts. On the other hand, if I am able to ignore the discomfort, and focus on something else, discomfort loses priority. What a concept. Discomfort loses priority, and we don't attend to it. What a great lesson for our kids!

By the way the circuitry that processes priorities is in the right anterior insular cortex (rAI). It feeds priorities to the anterior cingulate cortex (ACC) which takes action: behaviors, motor and emotional reactions and cognitive redirection. ....but that's a post for another day.

Monday, July 25, 2016

Just a short post today. I'd like to refer back to the last two posts (here and here) which discussed stereotypy and sensory craving. I forgot to mention in the second post that the intervention used by Rispoli, et al. is the same approach I take to sensory craving in my book, Hands on Activities for Children with Autism and Sensory Disorders. In the book, I discuss how to explore sensory activities to find a preferred type of activity. The book also contains 50 or so fun interventions including crafts.

Wednesday, July 20, 2016

In the previous post, I looked at the blurred lines across the (ASD) autism symptoms of stereotypy and sensory craving. This
post focuses on an intervention that may help both types of symptoms. The intervention is a well-conceived combination of
behavioral and sensory techniques that comes from a study by Rispoli, et al (2013).

The research team studied three children with stereotypic behaviors. Five-year-old Antonio has autism and vocal stereotypy in the form of a high-pitched squeal. Twelve-year-old Jeff has intellectual disabilities and seizure disorder. He hits tables, chairs and walls repeatedly with various hand-held objects. Four-year-old Joel has autism and bounces small things (balls, toys and breakable objects) onto the floor. All three boys were unable to engage in demanding group tasks because of their stereotypy. The researchers posed the question: If each child were allowed to engage in his behavior until he stopped of his own volition (was satiated), would he then be able to engage in the demanding group tasks. To test this, they set up a three phases process. First they analyzed each child’s behavior to see if he was a good fit for the study. Second, they looked for toys that matched the child's stereotypy and had him play with them to discover which toy was preferred. Last, they tested over a 4-5 week period to see if pre-satiation with the preferred toy before a demanding 15-minute group activity decreased the amount of stereotypy during the group activity and allowed each boy to focus on his work. (The answers were yes and yes.) The study while small used good methods; it was a blind, controlled study.The implementation details are below. The interventions (step three) can easily be done at home or school by a parent or teacher. The first two steps are the domain of behavioral or sensory therapists, but may be accomplished by an astute parent or teacher. Let's look at the details for putting this in place.

Step 1: Analysis

1.Analysis:
You note a stereotypic behavior that appears to have a sensory component. Note which senses appear to be stimulated by the behavior. Remember that movement is also sensed by the body. It is the combination of the vestibular sense (head movement) and the proprioceptive sense (body movement). Unless you discover otherwise (see the "unmatched preference" of step three), assume that the child is craving sensation and that his stereotypic activities are satisfying that craving.

2.To establish a baseline, count
the occurrences of the behavior: count the number of
times and the total amount of time he engages in stereotypy during a demanding
activity. Also note when (time, place, type of activity) the child engages in
the behavior.

Step 2: Discovering the Preferred Object

1. Identify
possible preferred activities for satiation tasks: Put together some optional
activities for him to engage in that might be just as engaging as the
stereotypy. Attempt to find activities that stimulate the exact same senses in the same way. A good preferred activity may be more intense than his
current one.

2. Put all of the candidate preferred activities (toys to help with stimming) in an otherwise empty room with the child on a few occasions. Let him play and see if a preferred object emerges. If you are unable to find a preferred activity that is similar to
the stereotypy, then try something else, perhaps access to a computer or a
cause-and-effect toy. This is called an unmatched
preference. The preferred toy for Antonio was a musical camera. Jeff was given an object he could use to strike walls and tables that would not hurt them. The choice for Joel was obvious; he was given a ball.

Here are examples:

a.For the child who lines things up, show him how
to stack and line-up Legos, and see if that becomes a preferred activity. This
is a big one for many kids.

b.For the child that flicks his wrist, try a punch
balloon.

c.If he is in constant motion, try a small
trampoline, a swing (this is huge!), climbing equipment or a ball pit (if you
have access to one). An older child may like riding a bike—perhaps on a
bicycle-built-for-two with the parent in front.

d.Finally, an example of an unmatched preference:
the child flicks his finger, but you’ve discovered that given the opportunity,
he would play with a cause and effect toy for a long time. This is his
preferred activity.

3.Practice
with the preferred activity: On successive sessions, let the child engage in
the activity for as long as he wants--until he has had enough. You will need to
know how long it typically takes for him to be satiated, so keep track of the
time. This is the satiation time.

Step 3: The InterventionThe intervention can be done prior to a demanding activity,
as a way of helping the child to self- regulate.

First, let the child have unlimited
time doing the preferred activity, that is let him do it until he is satiated.
Let’s say that he usually requires 22 minutes to be satiated, and then plan to have
him start the preferred activity about 25 minutes prior to the next task.

Afterwards, as he engages in the
demanding tasks, track his behavior to see if his stereotypy has
diminished. Counting the number of times and the total amount of time he
engages in stereotypy during the demanding activity. Do this over a period of
several sessions. If it appears to be helping, continue with the intervention
on a daily basis. If he acclimates to the preferred activity, then try
replacing it with something a little more intense or demanding. In some cases,
you may see that he no longer desires the preferred activity and that his
stereotypy has decreased, as well. This good outcome is possibly the result of increased
sensory integration skills.

In the study, the child was used as his own control. By performing the intervention every other
session, his behavior on days that he was satiated could be compared to behavior on days that he received no intervention and was not satiated. They noted that after a few
weeks, the behavior appeared to improve both on the days that the intervention
was done and when it was not done. Unfortunately, the researchers did not carry out the study long enough to see if the intervention
would lead to extinction of the behavior--which is a shame, because it might do so. I have seen satiation work as therapy with children in my
setting. I separately treated wo children who craved movement. When given unlimited time on a swing
twice a week, both lost interest in the swing after a month. One boy with this
result was then capable of sitting at attention in the classroom
without getting out of his chair on most
days. Sensory integration theory suggests this outcome, but to my knowledge,
this type of scenario has not been documented in the journals.

How long did the effect of the intervention last? Fifteen minutes? A few hours? The whole day? The
authors don’t discuss this, but the intervention is similar in nature to the
sensory diet which is thought to last 2 hours. In the sensory diet, children
are given 15 minutes (or so) of sensory stimulation usually including a movement activity every 2 hours as a means of
increasing self-regulation. A significant difference between satiation and the sensory diet is the inclusion of movement which is on its own self-regulatory. (BTW, the sensory diet has not yet been
sufficiently studied to validate its efficacy, but it is generally accepted as a
good practice.)

I still have additional articles to review from Behavior Modification's 2013 special issue on Stereotypy. So stay tuned for that.

An update: Rachel Scalzo's 2015 PhD thesis on satiation of stereotypy has made a significant addition to the literature by clarifying the intervention process. I'll keep an eye out for future journal articles from her. In the meantime, here is her thesis abstract.

Tuesday, July 12, 2016

It can
be difficult to accurately distinguish between sensory craving and stereotypy.
Both symptoms play a big role in autism and both are part of the ASD¹
diagnosis, so you might think they are distinct. But they're not. They can be
easily mistaken for each other and even overlap. Does it matter that we
identify exactly what is going on? Yes. How can we create successful
interventions without pegging the problem correctly?

Look at
the descriptions and examples below and see if you can pick out inherent
problems. See if you notice the areas of overlap and blurry lines
between them, and also with them and hyperactivity (ADHD²) and obsessive
behaviors (OCD).

Stereotypy: Rapp and Lanovaz³ say, "Stereotypy
is often characterized as repetitious, invariant behavior that generates its
own reinforcing consequences (rewards)." Examples are vocalizations,
flicking fingers, slapping things, nail biting, and similar habitual
activities. The DSM describes it in terms of motor movement or use of
objects and gives these examples: "simple motor stereotypes, lining up
toys, flipping objects, echolalia, idiosyncratic phrases."

Sensory
craving: I'll venture
this definition: goal-driven behavior to satisfy
a sensory need. The DSM more broadly talks about "unusual interest
in sensory aspects of the environment ... such as ... excessive smelling or
touching of objects, visual fascination with lights or movement."

Did you
catch any problems? Stereotypy is defined in terms of motor, craving in terms
of the senses—as if the two inhabit separate worlds or separate people. But
they don’t. Let’s look at a few cases and see how the symptoms might occur in
real life.

We’ll
start with the example of the child who frequently vocalizes simple sounds or
phrases. Is it echolalia--a motor repetition? Or is it sensory
seeking: fascination with the sounds she produces, or the sensation
in her throat? Or is she doing it for some other reason such as attention
seeking? Without knowing what is driving the behavior, it's hard to classify
it. In fact, the behavior may be driven by all of these factors.
The stereotypy may co-exist with sensory seeking, and once the child learns
that her behaviors draw attention, she may use them to do so.

How do
school professionals view this behavior? It will likely be a mixed bag. First,
behaviorists⁵ and
sensory therapists will agree that the child is being rewarded by the sensation
of certain sounds. She is craving sensory stimulation; but she is
also engaging in stereotypy: behavior that generates its own reward.
While there is definite overlap of stereotypy and sensory craving here, they
will probably name it stereotypy and sensory therapists will look for any
connection to craving. Teachers, who are with children for long periods and can
see patterns in their behaviors, will be more attuned to the possibility of
attention seeking.

Now
let's explore this a little further. What about the child who has vocal
tics. Does he fall into the categories of stereotypy or craving?
No. Tics are involuntary speech and are usually the result of stress and
anxiety.

How
about a child who talks constantly? We see this in Asperger's Syndrome and
it is often pegged as repetitive behaviors, but constant talking is
also a symptom of ADHD hyperactivity. How do you distinguish between
impulsive talking and self-rewarding ("He just likes
to hear himself speak") stereotypy? For the unpracticed observer, the
signs seem subtle, but the give-away to it being a repetitive behavior is
constant talking about a single topic (such as types of
aircraft). Finally, is the non-stop talking a sensory behavior?
That's possible, but less likely.

Let's
look briefly at a few more examples: children who touch everything or
sniff things. Are these considered sensory cravings? Almost certainly, but it
may be more than that. Some children learn about their world using alternate
sensory paths: smell or touch instead of vision and hearing, and so the seeking
behaviors may be a form of learning. But which came first: the craving or the
learning pattern? It’s hard to know. And to further complicate things, the
behavior can also be tagged as stereotypy, if she smells or touches the
same things over and over in an “invariant pattern”.

Finally, let’s ask if a
behavior that looks like stereotypy is actually obsessive compulsion
(OCD). Hmm, it could be. The child who touches things in a certain prescribed
way, may have OCD. The motivation for the behavior will be fear-based: "If
I don't move in this exact sequence, something bad will happen",
rather than the reward-based behavior of stereotypy. (The topic of
differentiating OCD from stereotypy is explored in an article by Chok and Koesler
in the September, 2014 issue of Behavior Modification journal, a special issue
devoted to stereotypy, and I may blog on that at a later time.)

You can see that symptoms
can be easily confused. In my years of teaching classes on the topic
of self-regulation, I heard numerous accounts of doctors confusing
craving or stereotypy with hyperactivity or OCD and giving children
ADHD or OCD meds. It's truly important to distinguish the nuanced behavior
so that the correct intervention is given.

In my next post, I'll look
at the approaches taken by behavioral and sensory therapists to stop these
behaviors. Sometimes the interventions are surprisingly alike.

Friday, July 8, 2016

The ASD¹ (autism) symptoms of sensory craving and stereotypy
are described separately within the ASD diagnosis in the DSM-5², so you might
think they are distinct from each other. But that is not the case. They can be
easily mistaken for each other, and at times they overlap with each
other. In the next two posts, I’ll take a look at the blurry lines between
them and with other similar issues: the hyperactivity of ADHD³,
tics, and obsessive compulsion. I'll discuss the implications for both
assessment and intervention.

Monday, June 27, 2016

Environmental Enrichment (EE) is an awesome protocol that has been shown to decrease autism symptoms and sensory issues and to increase receptive language and cognitive skills in children with ASD of all ages. It was designed as a low-cost program for parents to do at home. But, it can also be done in a school setting, or better yet, shared between home and school.

EE is a 6-month protocol with activities that change every two weeks. Parents/teachers select several multi-sensory activities from a list of 34 activities and do them for the two week period. They work with the child twice a day for about 15-20 minutes each. As the sessions progress, the child gains awareness of sensation and gains multi-sensory integration skills. The activities also build joint-attention skills, which are known to decrease autism severity.

The protocol is simply described in two published papers (listed below). They are open-access (available for free online). In addition, my Hands-On Activities book devotes 80 pages to the protocol, providing perhaps 200 activity variations and talking through program implementation details.